ABSTRACT
By now, everyone in the health eld should be familiar with the Institute of Medicine’s 2000 report To Err Is Human and its astonishing nding that between 44,000 and 98,000 Americans die each year as a result of medical errors (Kohn, Corrigan, and Donaldson 1999). e report served as a wake-up call and particularly drew attention to safety as “primarily a systems problem” (Leape, Berwick, and Bates 2002). is short chapter will focus on the systems issue, and introduce the reader to high reliability organizing (HRO) theory, a systems approach developed out of decades of studying failure and resilience.
